Body Alchemy LLC 2025 Intake Form

What is your name?

First Name

Last Name

What is your birth date?

Date

Are you male or female?

Male

Female

What city and state do you live in?

Are you single, married, and do you have any children? Please provide names and ages.

Who do you live with and/or surround yourself with? Are they supportive of your journey? How so?

What situations; peer pressure, work environment, stress levels, busy days, etc. do you find as a challenge, barrier, or interruption to your health journey?

Please list your top 3-5 areas of focus (you may also select all!)Note: many of these happen naturally as a result of achieving optimal health overall

Weight loss / Management

Gut Help

Hormone Balancing

Auto-immune or Disease Management

Muscle Building / Tailored Programming

Nutrition Education

Spiritual or Energetic Systems

Reducing Medication Use

Sleep and/or Nervous System Regulation

Behavioral & Disordered Eating (ie, binging, OCD calorie/macro counting, etc)

Overall Lifestyle Management

Other

Please elaborate on your selections by providing specific information or details as they pertain to your situation and goals.

How long do you anticipate working with Body Alchemy LLC

3 Months

3 - 6 Months

6 months or more

It takes as long as it takes!

What is your current weight?

What is your height?

Please provide pictures of your front, side, and back -or text/email.Wear clothing that best represents your current body composition. IE, sports bra, athletic shorts, swim suit. QUALITY LIGHTING PLEASE.

If you have a DEXA, InBody, or body compositions results, please upload here

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Please upload any lab-work from within the last year.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Please provide a brief weight history and/or description of body composition for each age bracket

Adolescence

Teenage

20-30s

30s-40s

40s-50s

60s+

Chronic or Past Diagnosis

Hashimoto's or Thyroid Disorder

Celiac Disease

PCOS

Type 1 or Type 2 Diabetes

Metabolic Syndrome/Insulin Resistance

IBS/IBD/SIBO

GERD/Acid Reflux

Chronic fatigue / fibromyalgia

Lupus or another autoimmune disease

Anxiety / Depression

ADD or ADHD

Infertility

Mold / Lyme / EBV

Heavy metal toxicity

Chronic viral or bacterial infections

Cancer - please specify

Other

Please include any other illness, medical diagnosis, injuries, or surgeries you've had in the past.

How often do you get sick each year? Examples: Stomach bug, cold, flu, infections

Are you more prone to illness during "cold/flu" seasons?

Do you have environmental allergies?Example: pollen, mold, dust

Do you experience a chronic runny nose or post-nasal drip?

Do you have water or itchy eyes?

Do you react strongly to alcohol, fermented foods, grains, or dairy?

How often do you feel fatigue during the day?

Are you more tired after eating?

Please list all medications you are currently on, or have used in the past for durations longer than 30 days (this includes antibiotics). Why are you or were you taking these? .

Please list all supplements you take consistently, or have used in the past for durations longer than 30 days. Why are you or were you taking these?

Did you receive COVID-19 vaccines or boosters?

Did you experience symptoms such as fatigue, inflammation, brain fog, sickness afterward?

Please list ANY family history (both immediate and extended) of health problems; mental health, disease, weight issues, etc, and the family member’s relation to you:Include your self as well if you have not already specified.

Do you experience indigestion, constipation, bloating, and/or diarrhea? If so, how often?

Which type most accurately depicts your typical bowel movement?Provide your answer in the next box.

Do you have any food sensitivities or digestive issues?

Have you taken long-term medication like antacids, NSAIDS, proton-pump inhibitors, or steroids?

Please describe your sleep quality by providing information regarding what time you go to bed and wake up, if you have trouble falling or staying asleep, and if you feel rested upon waking.

Please describe your energy quality by providing information regarding your daily schedule and activities, when you feel rested, and when you feel stressed. You may list out an example of daily or weekly schedule.

If female, are you currently menstruating? Please list cycle dates.

Are your cycles regular? Painful? Emotionally difficult?

Have you used hormonal birth control? How long? What kind(s)

Are you perimenopausal or postmenopausal.

If male, have you experienced signs of low testosterone such as low libido, mood shifts, weight gain, muscle atrophy?

Have you had your T levels tested? Please provide when levels at the time of testing.

Are you on or considering TRT?

Please list your current physical activity level and type of activities on a day to day and weekly basis. Please also note how many hours you are seated / sedentary.

Were you breastfed or formula fed as baby? If breastfed, for how long?

Were you born via vaginal delivery or C-section?

Were you sick often as a child?

Were you frequently on antibiotics as a child?

Were you prescribed any other medications in adolescence or early adulthood?

Did you receive standard childhood vaccinations?

Were you vaccinated at birth?

Have you ever received vaccines for travel or work?Example: malaria, yellow fever, typhoid

Have you ever experienced vaccine-related side effects?

Do you have personal concerns or questions about vaccinations?

Please describe your inner and / or outer environment during these stages of development. Note feelings, tragic events, or moments of unsease/insecurity that you remember.

Ages 1-7 (physical body)

Ages 8-14 (emotional body)

Ages 15-21 (mental body)

Did you play sports (or highly active) growing up? Which ones?

What forms of exercise do you enjoy or that you responded to in the past?

Did you ever have any formal weight lifting training? For how long?

Have you worked with a nutritionist, dietitian, naturopath, functional provider, or coach in the past? Please provide a further explanation.

Have you done GT testing, DUTCH, MRT, or other insight lab work?

What is your history with "diets", detoxes, gut protocols, or any other method of healing or weight loss? Please list all diets or food plans you have tried.

What worked? What didn't? What triggered you?

Please describe your current relationship to food and to alcohol.Examples: Emotional eating, sugar addict, restriction/binge cycle, confusion around hunger/fullness

Have you ever used an app to track calories or macronutrients? Which app did you use?

Are you confident reading nutrition labels and interpreting serving sizes?Have you used food scales or measuring cups?

Do you look for ingredients like certain oils, sugars, or additives?

What are your favorite foods to eat? What food are you adversed to?

How much water do you drink daily? What is the source?

Terms & Conditions* This field is required.

Do you understand that you are 100% free to make any choice regarding what you eat or drink at all times? This includes the decision to not eat or drink.

YESNO

Do you understand that any lack of transparency regarding your diet (what you eat and drink) and physical activity will only be a hinderance to your progress and outcome?Honesty is not the policy because it is the ONLY policy

YESNO

Do you understand that no one is responsible for your feelings/attitude/behaviors other than you?AKA you do not make someone "feel bad" and vice versa

YESNO

Do you understand that in order for your body to yield the results you desire, you will have to let go of the situations, attitudes, foods/beverages, and other lifestyle habits that disrupt your health and/or interfere with your goals?These may be temporary or indefinite.

YESNO

Will you reach out and ask Body Alchemy for help or guidance when you need it?.

YESNO

Do you understand that all physiological adaptations require acceptance, patience, and consistency?

YESNO

Are you willing to give your body the time and space (boundaries) it needs to heal, change, and reset its homeostasis?

YESNO

Will you communicate with your friends, family, co-workers about your dietary needs (or health goals) in an appropriate but direct fashion?

YESNO

Are you READY to make this commitment to your self and to your body?

YESNO

Please sign your name

Please select Meet & Greet to schedule our first official appointment over ZOOM or in-person.